Molecular epidemiology and clinical-laboratory aspects of chromoblastomycosis in Mato Grosso, Brazil.

INTRODUCTION: Chromoblastomycosis is a disease caused by melanized fungi, primarily belonging to the genera Fonsecaea and Cladophialophora, mainly affecting individuals who are occupationally exposed to soil and plant products. This research aimed to determine the clinical, epidemiological and laboratory characteristics of chromoblastomycosis in the state of Mato Grosso, Brazil. MATERIALS AND METHODS: Patients diagnosed with chromoblastomycosis treated at the Júlio Müller University Hospital, Cuiabá, Brazil, from January 2015 to December 2020, whose isolates were preserved in the Research Laboratory of the Faculty of Medicine of the Federal University of Mato Grosso. Isolates were identified by partly sequencing the Internal Transcribed Spacer (ITS) and ß-tubulin (BT2) loci. AFLP fingerprinting was used to explore the genetic diversity. Susceptibility to itraconazole, voriconazole, 5-fluorocytosine, terbinafine and amphotericin B was determined by the broth microdilution technique. RESULTS: Ten patients were included, nine were male (mean age = 64.1 years). Mean disease duration was 8.6 years. Lesions were mainly observed in the lower limbs. Predominant clinical forms were verrucous and scarring. Systemic arterial hypertension and type II diabetes mellitus were the predominant comorbidities. Leprosy was the main concomitant infectious disease. Fonsecaea pedrosoi was the unique aetiological agent identified with moderate genetic diversity (H = 0.3934-0.4527; PIC = 0.3160-0.3502). Antifungal agents with the highest activity were terbinafine, voriconazole and itraconazole. CONCLUSION: Chromoblastomycosis is affecting the poor population in rural and urban areas, mainly related to agricultural activities, with F. pedrosoi being the dominant aetiologic agent. All isolates had low MICs for itraconazole, voriconazole and terbinafine, confirming their importance as therapeutic alternatives for chromoblastomycosis.

Chromoblastomycosis.

Chromoblastomycosis (CBM), also known as chromomycosis, is one of the most prevalent implantation fungal infections, being the most common of the gamut of mycoses caused by melanized or brown-pigmented fungi. CBM is mainly a tropical or subtropical disease that may affect individuals with certain risk factors around the world. The following characteristics are associated with this disease: (i) traumatic inoculation by implantation from an environmental source, leading to an initial cutaneous lesion at the inoculation site; (ii) chronic and progressive cutaneous and subcutaneous tissular involvement associated with fibrotic and granulomatous reactions associated with microabscesses and often with tissue proliferation; (iii) a nonprotective T helper type 2 (Th2) immune response with ineffective humoral involvement; and (iv) the presence of muriform (sclerotic) cells embedded in the affected tissue. CBM lesions are clinically polymorphic and are commonly misdiagnosed as various other infectious and noninfectious diseases. In its more severe clinical forms, CBM may cause an incapacity for labor due to fibrotic sequelae and also due to a series of clinical complications, and if not recognized at an early stage, this disease can be refractory to antifungal therapy.

[Extensive cutaneous chromomycosis: Efficacy of combined terbinafine and cryotherapy]. / Chromomycose cutanée étendue : efficacité de l'association terbinafine et cryothérapie.

BACKGROUND: Chromomycosis is a chronic fungal skin infection, mainly affecting the limbs. It is responsible for severe morbidity and its treatment remains long and disappointing. Rarely described in Morocco, we report a new observation that has evolved very well under treatment combining terbinafine and cryotherapy over a short duration. CASE REPORT: A 56-year-old patient, immunocompetent, had a pustular and crusty placard on both forearms that had evolved for a year. Mycological examination showed fumagoid bodies and cutaneous biopsy showed epithelioid granulomas and giant cells without necrosis. The PCR confirmed a chromomycosis at Fonsecaea pedrosoi. HIV serology was negative. Treatment with terbinafine 250mg/d for 6months combined to cryotherapy resulted in complete remission with initial clinical improvement after only 3 weeks. DISCUSSION: Chromomycosis occurs increasingly in non-tropical areas. If diagnostic methods become more effective, management remains difficult and poorly codified. Terbinafine-cryotherapy combination would bring a lot of benefits with a little risk to bothpractitioner and patient. CONCLUSION: This combined treatment would constitute an excellent therapeutic alternative because of its efficiency, feasibility, low cost, method of administration and aesthetic result.

[Chromomycosis acquired in a non-tropical area: A case report]. / Une chromomycose contractée en zone non tropicale.

BACKGROUND: Chromomycosis, or chromoblastomycosis, is caused by cutaneous inoculation of dematiaceous fungi of telluric or plant origin. It is generally seen in tropical or subtropical zones. Treatment of the condition is known to be complex. Herein we report a case of chromomycosis contracted in a temperate region of Eastern Europe/Central Asia that was effectively treated with oral itraconazole and terbinafine in combination with cryotherapy. PATIENTS AND METHODS: A 44-year-old immunocompetent male subject consulted for a lesion on the buttocks that he had sustained 16 years earlier, and which, although never previously treated, had only become troublesome within the last few months. The examination revealed a large erythemato-squamous plaque containing a heterogeneous infiltrate. The diagnosis was based upon biopsy, with histological examination revealing sooty mould ; culture of a second sample showed the causative agent to be Fonsecaea pedrosoi. After 30 months of treatment combining oral terbinafine at a very high dose (1000mg/day), topical terbinafine and adjuvant cryotherapy, considerable, though incomplete, improvement was obtained. Finally, combined use of terbinafine (500mg/day) and itraconazole (200mg/day) led to clinical and histological cure. DISCUSSION: The possibility of acquiring chromomycosis other than in a tropical zone is slight but has nevertheless been described, particularly in Eastern Europe. In our patient, the exact source of contamination is unknown, although it may have been acquired through frequent horse-riding or use of saunas. This case confirms the efficacy of combined itraconazole and terbinafine against this condition, which is usually difficult to treat.

Combination therapy for an elderly patient with chromoblastomycosis caused by Fonsecaea monophora: a case report.

We report the first case of combined treatment using oral drugs, thermotherapy, and carbon dioxide fractional laser for an elderly patient with skin chromoblastomycosis caused by Fonsecaea monophora. Chromoblastomycosis is a chronic and refractory granulomatous disease of the skin and subcutaneous tissues caused by a group of dematiaceous fungi, which can cause teratogenesis, disability, and even cancer. One of the subtypes, F. monophora, is not only limited to the skin and subcutaneous tissues but also affects the central nervous system. Therefore, a timely and clear diagnosis, as well as active and effective treatment, are particularly important. This case report presents a 75-year-old male patient whose left forearm had a plaque with mild pruritus for more than three years. The patient's skin lesions were histopathologically examined, and the fungus on the surface of the scabbed skin was examined by fluorescence microscopy and cultured. The strains obtained by the culture were identified by morphological and molecular biology, and a drug susceptibility test was conducted in vitro. Histopathology revealed hyperkeratosis of the epidermis with pseudoepitheliomatous hyperplasia, chronic granulomatous changes in the dermis, and brown thick-walled sclerotic corpuscles both inside and outside giant cells. Septate hyphae and sclerotic corpuscles could be observed in the fungus on the surface of the scabbed skin by fluorescence staining, and black villous colonies could be observed in vitro. Under the scanning electron microscope, rhinocladiella was the primary sporulation type, and the conidia were oval. Molecular identification results showed that the similarity between its internal transcribed spacer (ITS) sequence and that of F. monophora, a Chinese strain (IFM41705), was the highest, reaching 100%. The results of the drug susceptibility test showed that the minimum inhibitory concentrations of itraconazole and voriconazole were 0.125 mg/L and 0.06 mg/L, respectively. The patient was given oral itraconazole 0.2 qd, combined with local thermotherapy and carbon dioxide fractional laser treatment. After 16 weeks, the microscopic examination of the fungus was negative, showing good efficacy.

A Novel Exophiala Species Associated With Disseminated Granulomatous Inflammation in a Captive Eastern Hellbender (Cryptobranchus alleganiensis alleganiensis).

The genus Exophiala is composed of ubiquitous, pigmented, saprotrophic fungi and includes both terrestrial and waterborne species. Though Exophiala species are generally considered opportunistic pathogens, exophialosis can be an important cause of morbidity and mortality in aquatic and semi-aquatic species. Over a 6-year period, a captive 32-year-old male eastern hellbender (Cryptobranchus alleganiensis alleganiensis), was treated for recurring, slow growing, ventral midline cutaneous masses. Excisional biopsies were characterized histologically by granulomatous dermatitis with low numbers of intralesional, pigmented fungal conidia and hyphae. Bacterial and fungal cultures of the masses and skin were negative on two separate submissions. Polymerase chain reaction amplification of a short fragment of the fungal 28S large subunit (LSU) ribosomal RNA was positive with 100% nucleotide sequence identity to several species of Exophiala. Following recurrence after successive rounds of antifungal therapy, euthanasia was elected. At necropsy, similar dermal granulomatous inflammation and intralesional pigmented fungal elements as observed in excisional biopsies formed a thick band in the dermis and extended through the coelomic body wall. Visceral dissemination was noted in the lung and kidney. Postmortem DNA sequence analysis of a large portion of the fungal LSU as well as the internal transcribed spacer (ITS) from a portion of frozen affected dermis identified the fungus as a novel species, Exophiala sp. 1 (UTHSCSA R-5437).

First case of chromoblastomycosis due to Phoma insulana.

Chromoblastomycosis is a chronic infection, caused by pigmented fungi affecting skin and subcutaneous tissues characterized by verrucous nodules or plaques. Fonsecaea pedrosoi and Cladophialophora carrionii are the prevalent agents in the endemic areas. Phoma is an uncommon agent of human infection and involved mainly with phaeohyphomycosis cases. The case of a patient with a history of laceration in foot followed by verrucous aspect and scaly lesions, which had evolved for 27 years is presented. On physical examination disease was clinically compatible with chromoblastomycosis and the microscopic examination of scales showed fumagoid cells. On culture a dematiaceous fungus was grown. The agent was confirmed to be Phoma insulana based on its morphology and PCR-sequencing. This fungal agent has not been previously reported in association with this pathology.

Presentación de un paciente con cromomicosis / Presentation of a Patient with Chromomycosis

La cromomicosis es una micosis subcutánea o profunda, de curso crónico, causada por un grupo de hongos, se caracteriza por la formación de nódulos cutáneos verrucosos, localizados comúnmente en miembros inferiores, de evolución crónica y difícil curación total. Se presentó un paciente de 34 años de edad, que hace cinco años le salieron placas (de tres a cuatro) dispuestas de forma lineal, aspecto papuloverrucoso en dorso del brazo izquierdo. Se indicó examen micológico, donde se informó la presencia Fonsecaea pedrosoi, para lo cual recibió tratamiento con fluconazol; por elevación de las transaminasas se interrumpió el tratamiento, luego se aplicó crioterapia y por último recibió tratamiento quirúrgico.

Chromomycosis is a subcutaneous or deep mycosis of chronic course, caused by a group of fungi; it is characterized by the formation of coetaneous verrucous nodules, commonly located in lower limbs, of chronic evolution and total difficult cure. A 34- year-old patient that 5 years ago presented plaques (three-four) of lineal form, papulo verrucous in dorsum of the left arm, mycosis exam was indicated, and the diagnosis of Fonsecaea pedrosoiwas confirmed, treatment with fluconazol was given that was interrupted due to transaminase increase, thus cryotherapy was given and later surgical treatment.

Detection of infectious fungal diseases of frogs inhabiting in Korea.

In recent years, there has been a rapid decrease in amphibian populations worldwide, and infectious diseases have been associated with this decline. Diseased frogs inhabiting Korea were collected from fields, and the diseases were identified by morphological and molecular analyses. Two fungal diseases-saprolegniasis and chromomycosis-were detected in the frogs. Saprolegniasis caused by Saprolegnia spp. was found in Rana plancyi chosenica from Gangwon-do and Rana huanrenensis from Chungbuk. Chromomycosis, which is caused by infection with Cladosporium cladosporioides, was detected in Rana catesbeiana from Busan.

Casuística de cromomicosis en el estado Bolívar (1987-2010) y evaluación de la sensibilidad in vitro de dos aislados de Fonsecaea pedrosoi / Chromomycosis cases in Bolivar State (1987-2010) and evaluation of the in vitro sensitivity of two Fonseca pedrosoi isolates

El objetivo de este estudio fue determinar la prevalencia de cromomicosis en un período de 23 años en dos hospitales de referencia del estado Bolívar. Se realizó un estudio retrospectivo, mediante la revisión de historias clínicas de pacientes con diagnóstico de cromomicosis, registrándose catorce casos de la enfermedad. El 78,6% correspondieron al sexo masculino, en su mayoría agricultores provenientes de zonas rurales; el 28,6% presentaron lesiones verrugosas. El tiempo de evolución de las lesiones osciló entre 5 meses y 35 años. Fonsecaea pedrosoi fue el agente etiológico aislado en tres (21,4%) de los cuatro pacientes en que las muestras fueron cultivadas. Sólo a dos aislados conservados de F. pedrosoi se les evaluó la sensibilidad in vitro mediante E-test®, demostrándose resistencia a los antifúngicos sistémicos: anfotericina B, 5-fluorocitosina, ketoconazol, fluconazol e itraconazol. Dos pacientes fueron tratados con itraconazol: uno de ellos mejoró; el otro presentó comorbilidad con micetoma eumicótico y falleció. La prevalencia de cromomicosis durante el período estudiado fue baja (0,6 casos/año), sin embargo esta infección representa un problema de salud en el personal de riesgo, principalmente agricultores y mineros del estado Bolívar, que presentan lesiones verrugosas de evolución crónica.

The purpose of this study was to determine chromomycosis prevalence during a 23-year period at two reference hospitals of Bolivar State. A retrospective study was carried out through the revision of clinical case histories of patients with a chromomycosis diagnosis, registering fourteen cases of this disease. Of these cases, 78.6% corresponded to males, most of them agricultural workers from rural areas; 28.6% presented verrucous lesions. The period of evaluation of the lesions varied between 5 months and 35 years. Fonsecae pedrosoi was the etiologic agent isolated in three (21.4%) of the four patients whose samples were cultured. Sensitivity was evaluated in vitro in only two cases through E-test®, showing resistance to systemic antifungals agents: amphotericine-B, 5-fluorocytosine, ketoconazole, fluconazole and itraconazole. Two patients were treated with itraconazol, one of them improved and the other presented co-morbility with eumycotic mycetoma and died. Chromomycosis prevalence during the period studied was low (0.6 cases/year); nevertheless, this infection constitutes a health problem for risk populations, mainly agricultural and mining workers at Bolivar State who present verrucous lesions with a chronic evolution.

Cromomicosis: reporte de un caso incapacitante / Chromomycosis: report of a disabling case

La cromomicosis es una micosis profunda subcutánea producida por hongos dimórficos que de forma habitual habitan en restos vegetales. Se presenta el caso de un paciente de 51 años que seis años antes del ingreso se dedicaba a la fabricación de tejas en Madre de Dios, Perú; donde sufrió una lesión inicial papular en una pierna la cual se extendió hasta comprometer los cuatro miembros, con lesiones verrucosas que lo llevaron a la discapacidad. Se observaron cuerpos fumagoides en la biopsia de piel. El paciente fue hospitalizado y recibió curaciones tópicas, antibioticoterapia y terbinafina. Fue dado de alta al cabo de dos meses con mejoría clínica.

Chromomycosis is a deep subcutaneous mycosis caused by different dymorphic fungi species that normally live in vegetal debris. We report the case of a 51 year-old patient that six years previous to the evaluation worked making roof tiles in Madre de Dios, Peru; where he presented an initial papular lesion in a leg, which continued expanding until the 4 limbs were affected with disabling verrucous lesions. Fumagoid cells were found in the skin biopsy. The patient was hospitalized and received topical cleaning, antibiotics and terbinafine. He was discharged two months later with clinical improvement.

Cromomicosis: una endemia rural en la región noroccidental en Venezuela / Chromomycosis: rural endemic in the north-western region of Venezuela

INTRODUCCIÓN: la cromomicosis, descrita por Max Rudolph en 1914, es una micosis subcutánea de desarrollo crónico, que se adquiere generalmente a partir de un traumatismo cutáneo y es causada por hongos dematíaceos. En Venezuela se ha reportado en todo el país aunque hay franco predominio en los estados de Lara, Zulia y Falcón. OBJETIVO: establecer algunos factores que pudieran explicar la endemia en la zona rural del estado de Falcón, Venezuela. MÉTODOS: se procedió a la detección in vitro de Cladophialophora carrionii a partir de la vegetación típica de esta región, semiárida, descrita como "bosque xerófilo de espinar". Se realizó además, búsqueda activa de casos clínicos entre los habitantes de la zona, mediante examen directo y cultivo de las escamas obtenidas a partir de lesiones y se trató de establecer, la existencia un factor de susceptibilidad hereditario mediante el cálculo del factor de heredabilidad de Falconer y la metodología de problemas genéticos heredables de Arias. RESULTADOS: se pudo aislar C. carrionii a partir de especies xerófilas abundantes en la zona: Prosopis juliflora; y varias cactáceas. La casuística acumulada, en nuestro estado representa 54,4 % (490/900) de todos los casos reportados en Venezuela, desde 1983 hasta 2005. La mayoría de los pacientes fueron infectados por C. carrionii y refirieron traumas frecuentes con espinas de cactáceas. Mediante estudios genealógicos se demostró la concentración de los casos en grupos familiares (hasta 11 % superior a la comunidad) así como un factor de heredabilidad de 65 % y alta frecuencia de matrimonios consanguíneos (25 %) asociados con 7 % de personas con cromomicosis. CONCLUSIONES: se consideró que se trata de una endemia rural, laboral y familiar, posiblemente relacionada con un factor de susceptibilidad heredable.

INTRODUCTION: chromomycosis, described by Max Rudolph in 1914, is a chronic subcutaneous mycosis that are generally caught from a cutaneous trauma and caused by dematiaceous fungi. This disease has been reported throughout Venezuela, but it is predominant in the states of Lara, Zulia and Falcón. OBJECTIVE: to ascertain some factors that might explain the endemic at Falcon State rural zone. METHODS: in vitro detection of Cladophialophora carrionii from the typical vegetation of this semiarid area known as "xerophilous woods of prickles" and also, active search of clinical cases among inhabitants of this area through direct testing and culture of flakes from skin lesions. It was intended to determine a hereditary susceptibility factor through the estimation of Falconer´s heritability factor and Arias´ methodology of heritable genetic disorders. RESULTS: it was possible to isolate C. carrionii from abundant xerophilous species in the area such as Prosopis juliflora and several Cactaceae. The accumulated casuistry in our state accounts for 54,4% (490/900) of all cases reported in Venezuela from 1983 to 2995. Most of the patients were infected by C. carrionii and they mentioned frequent injures by cactaceae prickles. On the basis of genealogical studies, it was proved that cases were concentrated in family groups (up to 11% higher than in the community) as well as 65% heritability factor and high frequency of blood-related marriages (25%) associated with 7% of people affected by chromomycosis. CONCLUSIONS: it was concluded that this is a rural, work and family endemic that is likely associated with a hereditary susceptibility factor.

Respuestas inflamatorias y de anticuerpos contra Cladophialophora carrionii en caprinos / Inflamatory and Antibody Responses against Cladophialophora carrionii in Goats

Cladophialophora carrionii es un hongo dimórfico con melanina que causa en humanos una micosis profunda, localizada y crónica llamada cromomicosis, y se adquiere a través de la inoculación con espinas de cactáceas infectadas. El estado Falcón es una zona endémica para esta enfermedad, donde las poblaciones están integradas principalmente por campesinos criadores de caprinos. El objetivo de este trabajo fue evaluar la respuesta inmunitaria humoral e inflamatoria contra C. carrionii en caprinos con el fin de conocer la interacción hospedador-parásito en un animal usualmente considerado como resistente a la infección, a pesar de su exposición permanente a las espinas infectadas. Se inocularon seis cabritos con 1×10(6) células de C. carrionii, vía subcutánea, en la tabla del cuello. Se midió la temperatura corporal de cada animal y se tomaron muestras de sangre completa y suero para análisis hematológicos y ensayos inmunoenzimáticos (ELISA) dos veces a la semana. Se midió el diámetro de la piel 24 y 48 horas después de la inoculación. La respuesta inflamatoria en el sitio de inoculación fue notoria a las 48 horas. No hubo respuesta significativa de anticuerpos en los animales inoculados a partir de los 50 días post-inoculación. Se confirma que la respuesta celular es importante en la resistencia contra C. carrionii, pero la respuesta de anticuerpos parece no ser relevante en esta especie animal.

Cladophialophora carrionii is a dimorphic fungus with melanin which causes a deep, localized and chronic mycosis in humans, named chromomycosis, acquired through inoculation with cactuses infected-spines. Falcon state is an endemic zone to this disease, where human populations make use of goat breeding as their main way of living. The objective of this work was to evaluate both humoral immune and inflammatory responses against C. carrionii in goats to improve knowledge about host-parasite interactions in a species usually considered as infection-resistant, in spite of permanent exposition to infected spines. Six kids were inoculated with 1 ×10(6) cells of C. carrionii, by subcutaneous route on the neck. Blood and sera samples for hematological and immunoenzimatic tests were taken and body temperature was also measured. The diameter of the inoculated skin was also evaluated 24 and 48 hours post-inoculation. Inflammatory response was considerable at 48 hours. There was no valuable response of antibodies. It is established that inflammatory response is important in resistance against C. carrionii, but antibody response seems not to be relevant for this animal specie.